My Pre-Admission Information:

First Name: (Legal Name):
/ Middle Name:
Last Name:
/ Full Maiden Name (First, Middle, Last):
Your Date of Birth: / City, State, Country of Your Birth:
Do you wish to receive phone calls and visitors while you are here in the hospital?
Yes No / Are you open to receiving a visit from clergy if he/she is in our facility? Yes No
Social Security Number:
/ Faith/ Name of Church (optional):
Address: Apt # :
City: / State: / Zip Code: / County:
Do you live within city limits? Yes No Name of the township?
Mailing address if different than above:
May we have your email address to register you for MyHealth, a 24/7 access point for your Northfield Hospital & Clinics health info, lab results, appointment results/viewing, messaging your MD, etc.?
Email Address: Decline
I am already signed up I have already accessed MyHealth Account Help set up for my baby
Home Phone: Cell Phone:
Maternal Race: “We are required by state and federal law to ask you about your country of origin, ethnicity, race and preferred language. Your answers will help us provide the best care for all of our patients. We will keep your information private and confidential.” This will also be used for the birth certificate. (Please mark all that apply & specify country of origin as applies)
White Non Hispanic/ Latino Hispanic/ Latino:
Black or African American:
Asian:
American Indian or Alaskan Native ( Tribe: _)
Native Hawaiian/ Other Pacific Islander:
Other:
In what language can we serve you best? English Other:
Emergency Contact (Someone that does not live with you) City:
Name: Relationship:
Telephone# Cell#
Occupation: Employer:
Phone# Address:
City: State: Zip Code:
Insurance Information: Private Ins. Medicaid Self Pay Other:
Guarantor on card: (OB will ask to Copy your Insurance Card)
You will want to notify your insurance carrier of the new baby, than notify the hospital Billing office with the new baby’s insurance information.
Do we have your permission to release your baby’s name and information to the radio/newspaper?
Yes No
Do you participate in WIC? No Yes Month of pregnancy WIC began (1st,2nd,…):
Last Menstrual Period: mo/da/yr: Unknown
Number of living children (not including this one): Date of last live birth: mo/yr:
Number of children who died after the birth:
Number of Ectopic, Miscarriage, Stillbirth, Terminations: Date last occurred: mo/yr:
With this pregnancy have you had: Infertility Meds/Procedure:
Steriods for lung maturity Amniocentesis Preterm Labor Meds None

____OB to Fax this page & Copy of Ins. Card to the Front Desk (Fax #1481) Mark here: Single Married

Birth Certificate Information:

Do you want us to apply for a Social Security Number for your child? Yes No
Should receive it by 3-4 weeks after delivery in the mail to the address you have provided.
Marital Status: Married Single Divorced (month/year of divorce)
Married
Are you legally married? (at birth, conception or any time between)
Yes No
If you were married at any time during the pregnancy, even if you are divorced or widowed now, your spouse is a legal parent of your baby and his/ her name and place of birth will appear on the birth certificate.
If you are married and your husband is NOT the father of the baby, do you wish to complete a Husband’s Non-Paternity Statement and a Voluntary Recognition of Parentage?
N/A Yes No
(Both forms are required to remove the husband’s name and add the father.) / Single
If you are single and would like the father’s name on this birth record, you and the biological father can sign a Voluntary Recognition of Parentage (ROP) form. This means the father accepts legal responsibility for this child.
Yes We will sign a Recognition of Parentage (ROP) form, after watching DVD
No the Recognition of Parentage will not be signed at this time. I understand no father’s information will appear on the birth certificate.
If you are single, your baby’s birth record is considered confidential unless you request a public record. Confidential birth records may be purchased by a parent or guardian of the child, the child at age 16, or disclosed according to court order, but they are not available for grandparents, siblings or spouses.
Yes Change the birth record to a public record
No Leave the birth record as a confidential record
Father or second parent’s information (Legal Name)
First Name: / Middle Name: / Last Name:
Date of Birth (Month/Day/Year): / Birthplace- State or Foreign Country: / Birthplace- City:
Social Security Number: / Mailing Address Same as mother’s address:
Father’s Race: Check all that apply and specify country of origin as applies in the blank
White Non Hispanic/ Latino Hispanic/ Latino :
Black or African American:
Asian:
American Indian or Alaskan Native ( Tribe: )
Native Hawaiian/ Other Pacific Islander:
Other:
Parents’ Education
Mother Father
8th Grade or less
9th-12th Grade, no diploma
High school graduate or GED completed
Some college credit, but no degree
Associate degree (e.g. AA, AS)
Bachelor’s degree (e.g. BA, AB, BS)
Master’s degree (e.g. MA, MS, MEng, Med, MSW, MBA)
Doctorate (e.g. PhD, EdD, or Professional degree (MD, DDS, DVM)

BC-FTBC-10/2015 rev